ED Scribe - FINAL EXAM/easy and accurate/2025
easy pass
Medical Decision Making (MDM) - The physician's thought process
Pain vs. Tenderness - Patient's feeling vs. physician's assessment
What does distress mean? - The doctor's judgment of discomfort
Baseline - An individual's normal state of being
What does Auscultation mean? - Listening with a stethoscope
Palpation - The act of pressing on an area by the doctor
Inpatient - Admitted to the hospital overnight
Outpatient - Seen and sent home the same day
What is the ED flow (overview)? - 1. Check in and Chief Complaint 2. Physician
assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition
What is the ED flow before orders are made? - 1. Arrival 2. Triage 3. Vital Signs / Bed
Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE
,What is the ED flow after orders are made? - 1. Differential Dx 2. Physician orders > labs,
imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition
What is the general documentation template? - HPI > ROS > PHx > PE > ED course >
Disposition
Thyroid problem means.. - Usually Hypothyroidism, sometimes hyperthyroidism
"I only take pills for my diabetes" means.. - Non-Insulin Dependent Diabetes Mellitus -
NIDDM
"I take shots (insulin) for my diabetes" means.. - Insulin Dependent Diabetes Mellitus -
IDDM
Heart disease means.. - Usually Coronary Artery Disease - CAD
Heart attack means.. - Myocardial Infarction - MI and CAD
Irregular heartbeat means.. - Atrial Fibrillation (A-Fib)
Murmur means.. - Heart murmur
Episodes of abnormally fast/racing heartbeat means.. - Supraventricular Tachycardia -
SVT
Emphysema/Chronic Bronchitis means.. - Chronic Obstructive Pulmonary Disease - COPD
,Blood clot in lung means.. - Pulmonary Embolism - PE
Reflux means.. - Gastroesophageal Reflux Disease - GERD
Ulcer means.. - Gastric Ulcer or Peptic Ulcer Disease
Hepatitis means.. - Hepatitis A, Hepatitis B, or Hepatitis C
Crohn's/UC means.. - Crohn's Disease or Ulcerative Colitis
Kidney infection means.. - Pyelonephritis - Pyelo
Kidney stones means.. - Renal calculi
"I'm on dialysis" means.. - Chronic Renal Failure - CRF or End Stage Renal Disease - ESRD
on dialysis
Enlarged prostate means.. - Benign Prostate Hypertrophy - BPH
What is the convention for documenting gynecological PMHx? - G: P: A:
Stroke means.. - Ischemic Cerebrovascular Accident - CVA
Mini-stroke means.. - Transient Ischemic Attack - TIA
, Seizures means.. - Seizure disorder/Epilepsy
Brain bleed means.. - Hemorrhagic CVA
"I drink a lot" means.. - ETOH abuse or Alcoholism
"I do drugs" means.. - Substance abuse
"Blood clot in my leg" means.. - DVT
"Bulge in my aorta" or "Triple A" - Abdominal Aortic Aneurysm
"Bad blood flow to my legs" means.. - Peripheral Vascular Disease - PVD
"Numbness in my legs" means.. - Peripheral Neuropathy
Bulging/Herniated disc means.. - Degenerative Disc Disease - DDD
What does Arthritis mean? - Osteoarthritis, Rheumatoid Arthritis
Joint pain (chronic) means.. - Degenerative Joint Disease -DJD
Weak/fragile bones means.. - Osteoporosis
Spread to my means.. - With metastases to the..
easy pass
Medical Decision Making (MDM) - The physician's thought process
Pain vs. Tenderness - Patient's feeling vs. physician's assessment
What does distress mean? - The doctor's judgment of discomfort
Baseline - An individual's normal state of being
What does Auscultation mean? - Listening with a stethoscope
Palpation - The act of pressing on an area by the doctor
Inpatient - Admitted to the hospital overnight
Outpatient - Seen and sent home the same day
What is the ED flow (overview)? - 1. Check in and Chief Complaint 2. Physician
assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition
What is the ED flow before orders are made? - 1. Arrival 2. Triage 3. Vital Signs / Bed
Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE
,What is the ED flow after orders are made? - 1. Differential Dx 2. Physician orders > labs,
imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition
What is the general documentation template? - HPI > ROS > PHx > PE > ED course >
Disposition
Thyroid problem means.. - Usually Hypothyroidism, sometimes hyperthyroidism
"I only take pills for my diabetes" means.. - Non-Insulin Dependent Diabetes Mellitus -
NIDDM
"I take shots (insulin) for my diabetes" means.. - Insulin Dependent Diabetes Mellitus -
IDDM
Heart disease means.. - Usually Coronary Artery Disease - CAD
Heart attack means.. - Myocardial Infarction - MI and CAD
Irregular heartbeat means.. - Atrial Fibrillation (A-Fib)
Murmur means.. - Heart murmur
Episodes of abnormally fast/racing heartbeat means.. - Supraventricular Tachycardia -
SVT
Emphysema/Chronic Bronchitis means.. - Chronic Obstructive Pulmonary Disease - COPD
,Blood clot in lung means.. - Pulmonary Embolism - PE
Reflux means.. - Gastroesophageal Reflux Disease - GERD
Ulcer means.. - Gastric Ulcer or Peptic Ulcer Disease
Hepatitis means.. - Hepatitis A, Hepatitis B, or Hepatitis C
Crohn's/UC means.. - Crohn's Disease or Ulcerative Colitis
Kidney infection means.. - Pyelonephritis - Pyelo
Kidney stones means.. - Renal calculi
"I'm on dialysis" means.. - Chronic Renal Failure - CRF or End Stage Renal Disease - ESRD
on dialysis
Enlarged prostate means.. - Benign Prostate Hypertrophy - BPH
What is the convention for documenting gynecological PMHx? - G: P: A:
Stroke means.. - Ischemic Cerebrovascular Accident - CVA
Mini-stroke means.. - Transient Ischemic Attack - TIA
, Seizures means.. - Seizure disorder/Epilepsy
Brain bleed means.. - Hemorrhagic CVA
"I drink a lot" means.. - ETOH abuse or Alcoholism
"I do drugs" means.. - Substance abuse
"Blood clot in my leg" means.. - DVT
"Bulge in my aorta" or "Triple A" - Abdominal Aortic Aneurysm
"Bad blood flow to my legs" means.. - Peripheral Vascular Disease - PVD
"Numbness in my legs" means.. - Peripheral Neuropathy
Bulging/Herniated disc means.. - Degenerative Disc Disease - DDD
What does Arthritis mean? - Osteoarthritis, Rheumatoid Arthritis
Joint pain (chronic) means.. - Degenerative Joint Disease -DJD
Weak/fragile bones means.. - Osteoporosis
Spread to my means.. - With metastases to the..
